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ASTHO US-Affiliated Pacific

(USAPI) Profile Report

Introduction This report marks the release of the Association of and Territorial Health Officials (ASTHO) Profile Survey report on the US-affiliated Pacific Islands (USAPI). The ASTHO Profile Survey is the only comprehensive source of information about state, territorial, and freely- public health agency activities, structure, and resources. The Profile survey aims to define the scope of public health services, identify variations in practice among agencies, and contribute to the development of best practices in governmental public health. This is the third survey in a series; prior surveys were completed in 2007 and 2010.

The US-affiliated Pacific Islands (USAPI) consists of three : American , the Commonwealth of the Northern and ; and three independent in free association with the United States: the Federated States of , the of the , and the Republic of .

Methods In October 2012, ASTHO launched the third iteration of the Profile Survey, sending a link to the web- based survey to senior deputies from the 50 states, the of Columbia, the Atlantic US territories and the USAPI. The 121-question instrument covered the following topic areas:  Agency structure, governance, and priorities;  Workforce;  Agency activities;  Planning and quality improvement;  Health information management; and  Finance.

Along with general instructions, senior deputies received recommendations on the most appropriate staff to fill out each section of the survey. The survey could be filled out by multiple personnel in multiple sittings. While senior deputies were asked to complete the survey by December 1, 2012, the administration system was held open until May 2013 to allow as many states, territories, and freely associated states to complete the survey as possible. ASTHO received assistance in collecting USAPI data from the Pacific Health Officer Association (PIHOA), including assistance in data entry of handwritten responses to the survey. Five of the six USAPI responded to the survey, for a response rate of 83 percent.

USAPI Report The results from the states and the District of Columbia were released in a report in June 2014. Differences in public health and general infrastructure, in jurisdictional governance, and different social and environmental impacts on health warranted a separate report focusing specifically on the USAPI. While these individual also differ from one another culturally, politically, and socially, there are more similarities among the five responding jurisdictions than between the five jurisdictions and the US states.

Considerations for the Report

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report There are a number of contextual considerations to keep in mind while reading this report. First, the data included in this report were collected between October 2012 and May 2013; therefore, the status of some items may have changed since then. Secondly, like health agencies in the United States, health agencies in the USAPI rely heavily on categorical federal funding to support their activities and functions. However, health agencies in the USAPI have fewer, more limited sources of discretionary funding than health agencies on the US . In some cases, the health agency and its activities in the USAPI may be nearly exclusively funded through federal funds given limited tax bases. Thus, many of the functions and services provided by health agencies in the USAPI may be determined by the agency’s grants and sources of funding.

The same survey instrument was used to collect data from both the US mainland and the USAPI in order to have uniform and comparable data; since the closure of the survey ASTHO has developed better institutional knowledge about the organization and delivery of public health services in the USAPI and ways in which it may differ considerably from the US mainland. Thus, some of the information was collected with a US mainland lens which may not be as relevant to the USAPI. For example, differences in the USAPI health agencies’ infrastructure and capacity for some functions and services, such as data collection, surveillance, and epidemiology as compared to health agencies on the US mainland may mean that the types of activities performed under those broad categories in the USAPI differ from the mainland US. Also, there may be differences in interpretation for some items in this survey. For example, in many of the USAPI, the health department is closely connected with the local hospital. As such, the concept of quality improvement may sometimes be understood in the context of quality assurance and hospital practices, as opposed to the shared understanding in health agencies in the US of quality improvement in the context of health agency performance. Also, different cultural norms may make certain response options for questions less relevant to the USAPI jurisdictions. For example, several questions include information about agency activities related to nursing homes, but in many of the USAPI jurisdictions the elderly more often live in family homes. It is important to take these items into consideration when reading this report and when making comparisons to state health agencies.

Agency Activities in the US-Affiliated Pacific Islands Like public health agencies in the US states, health agencies in the USAPI perform a wide range of functions and activities to promote and protect the health of citizens in their jurisdictions. Below is the analysis of select functions and activities directly performed by the five responding health agencies.

Immunization Services The responding health agencies reported directly providing a range of immunization services. Table 1 shows the immunization services provided by each .

Table 1. Immunization Services Directly Provided by Health Agency, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Vaccine order X X X X X management: adult

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Vaccine order X X X X X management: childhood Vaccine order X X X management: international travel Vaccine X X X X X administration: adult Vaccine X X X X X administration: childhood Vaccine X X X administration: international travel Key findings related to immunization services include:  One-hundred percent of agencies reported directly performing both vaccine order management and administration for both childhood and adult immunizations.  Sixty percent of agencies reported directly performing both vaccine order management and administration for international travel immunizations.

Screening for Diseases and Conditions Table 2 displays the responding health agencies and the screenings for diseases and conditions they reported directly performing.

Table 2. Screenings for Diseases and Conditions, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Asthma X X X Blood lead X X X BMI X X X X X Breast/cervical X X X X X cancer Colon/rectum X X X X cancer Other cancer X X X X screenings Cardiovascular X X X X disease Diabetes X X X X X

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Hypertension X X X X X HIV/AIDS X X X X X Other STDs X X X X X Newborn X X X X X screening Prediabetes X X X X X Tuberculosis X X X X X Other X X X X X Key findings from this table include:  The majority of agencies reported directly performing the majority of screening activities included on the survey.  Other screenings included Hansen’s disease and oral health screenings, among others.

Laboratory Services Health agencies often provide a range of laboratory services. Table 3 displays the laboratory services that the responding health agencies reported directly performing. It is important to note that given the infrastructure in some of the responding jurisdictions, laboratory samples may be shipped off of the island for analysis.

Table 3. Laboratory Services, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Bioterrorism agent testing Blood lead X X screening Cholesterol X X X screening Foodborne X X X illness testing Influenza X X X typing Newborn X X X X screening Biomonitoring X X X Other X X Key findings from Table 3 include:  The laboratory activity that the largest percentage of health agencies reported directly providing was newborn screening (80 percent).  Sixty percent of responding health agencies reported directly performing lab services for cholesterol screenings, foodborne illness testing, influenza typing, and biomonitoring.

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report  None of the responding agencies reported directly performing bioterrorism agent testing.

Registry Maintenance Health agencies maintain registries as part of federal mandates and to promote the health and wellbeing of their residents. Table 4 shows the registry maintenance activities that the responding agencies reported directly performing.

Table 4. Registry Maintenance, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Birth defects X X X registry Cancer registry X X X X Immunization X X X X X registry Diabetes X X X X X registry Other X X Points of note from this table include:  The majority of respondents reported directly maintaining the majority of registries included on the survey.  Other registries included newborn hearing and STD registries, among others.

Treatment for Diseases or Conditions In addition to screening for diseases and conditions, many health agencies also directly provide treatment services for a range of diseases and conditions. Table 5 displays the treatment services for select conditions that the responding agencies reported directly performing.

Table 5. Treatment for Diseases and Conditions, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Asthma X X X X Blood lead X X X Breast/cervical X X cancer Colon/rectum X X cancer Coronary heart X X X X disease Diabetes X X X X X Hypertension X X X X X

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report HIV/AIDS X X X X X Obesity X X X X X Other cancers X X X Other STDs X X X X X Tuberculosis X X X X X Other Key findings from Table 5 include:  One-hundred percent of respondents reported directly performing treatment services for diabetes, high blood pressure, HIV/AIDs, obesity, other STDs, and tuberculosis.  In contrast, only 40 percent of respondents reported directly performing treatment services for breast/cervical cancer and colon/rectum cancer.

Maternal and Child Health Services The maternal and child health services performed directly by the responding health agencies are displayed in Table 6.

Table 6. Maternal and Child Health Services, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Child nutrition X X Children with X X X X X special healthcare needs Comprehensive X school clinical health services Early X X X intervention EPSDT X X X Family X X X X X planning Home visits X X X X X Non-WIC X X nutritional assessments and counseling Obstetrical X X X X care Prenatal care X X X X X Comprehensive X X X X X primary care

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report clinics for children School health X X services Well child X X X services WIC X Key findings from Table 6 include:  One-hundred percent of responding agencies reported directly performing services for children with special health care needs, family planning, home visits, and prenatal care.  In contrast, only 20 percent of respondents reported directly providing comprehensive school health clinics and WIC.

Other Clinical Services Health agencies often provide a variety of clinical services to individuals beyond disease screening and treatment. Table 7 displays select other clinical services directly provided by the responding agencies.

Table 7. Other Clinical Services, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Child X X protection and medical evaluation Comprehensive X X X X primary care clinics for adults Correctional X health Disability X X X X Disability X X determination Domestic X X violence victim services Home health X X X Managed X X care/medical homes

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Mental health X X X X education and prevention Mental health X X X X treatment Oral health X X X X X Pharmacy X X X X Physical X X X therapy Rural health X X X Sexual assault X victim services Nursing home eligibility Substance X X abuse education and prevention Substance X X abuse treatment Points of note from Table 7 include:  One-hundred percent of responding agencies reported directly performing oral health services, while 80 percent reported directly performing comprehensive primary care for adults, disability, mental health education and prevention, mental health, and pharmacy services.  Just 20 percent of agencies reported directly providing correctional health services or sexual assault victim services, and none of the responding agencies reported directly providing nursing home eligibility services.

Data Collection, Epidemiology, and Surveillance Activities Health agencies are often critical players in data collection, epidemiology, and surveillance activities. Table 8 displays the responding agencies and the data collection, epidemiology, and surveillance activities they reported directly performing.

Table 8. Data Collection, Epidemiology, and Surveillance Activities, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Adolescent X X X behavior Behavioral risk X X X X factors

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Cancer X X X X X incidence Chronic X X X X X disease Infectious X X X X X disease Environmental X X X health Foodborne X X X X illness Injury X X X Morbidity X X X X Perinatal X X X X events and risk factors Reportable X X X X X diseases Syndromic X X X X surveillance Uninsured X X outreach and enrollment Vital statistics X X X X Key findings from Table 8 include:  The majority of respondents reported performing the majority of data collection, epidemiology, and surveillance activities included in the survey.  However, just 40 percent respondents reported directly performing data collection, epidemiology, or surveillance activities related to outreach and enrollment for the uninsured.

Population-Based Primary Prevention Services Health agencies provide a wide range of population-based primary prevention services to promote health among residents in their jurisdictions. Table 9 displays select population-based primary prevention services and whether the responding agencies reported directly providing the service.

Table 9. Population-based Primary Prevention Services, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Abstinence- X X only sex education Asthma X X X X Diabetes X X X X X

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report HIV X X X X X Hypertension X X X X X Injury X X X X Mental illness X X X X Nutrition X X X X Physical X X X X activity Sex education X X X X X STDs X X X X X Skin cancer X X X Substance X X X abuse Suicide X X X Tobacco X X X X X Unintended X X X X pregnancy Violence X X X X Key findings from Table 9 include:  The majority of responding agencies reported directly performing the majority of population- based primary prevention activities included in the survey.  However, just 40 percent of agencies reported directly performing population-based primary prevention activities related to abstinence-only sex education.

Regulation, Inspection, and Licensing Activities Health agencies are often involved in the enforcement of laws that protect health and promote safety. The six regulation, inspection and licensing activities directly performed by the greatest percentage of agencies were food services (100%), food processing (80%), and clinics, hotels, schools, and smoke-free ordinances (all 60%). Forty percent of respondents reported directly performing regulatory activities for childcare facilities, cosmetology, EMS, hospitals, private drinking water, public drinking water, septic systems, solid waste disposal sites and tobacco retailers; 20 percent reported directly performing activities for beaches, biomedical waste, body piercing/, housing, jails/prisons, laboratories, local public health agencies, long term care facilities, migrant housing, milk processing, nursing homes, shellfish, public pools, and the trauma system. No respondents reported directly performing regulatory activities for acupuncture, assisted living, campgrounds/RVs, hospice, lead inspection, mobile homes, occupational health, outdoor air quality, solid waste haulers, tanning salons, and others.

Professional Licensure Activities Table 10 displays the professional licensure activities and the responding agencies reporting directly performing those activities.

Table 10. Professional Licensure Activities, 2012

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Dentists X X X X X Nurses X X X X X Pharmacists X X X X Physicians X X X X X Physician X X X assistants Other X X X Key findings from Table 10 include:  The majority of respondents reported directly performing professional licensure activities for all of the health professionals included in the survey.  Other professionals includes allied health professionals, ophthalmologists, and occupational therapists, among others.

Environmental Health Activities Table 11 displays the responding health agencies and the environmental health activities they reported directly performing.

Table 11. Environmental Health Activities Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia Islands Animal control Collecting X unused pharmaceuticals Coastal zone X management Environmental X X X epidemiology Food safety X X training and education Groundwater X X protection Hazardous X X waste disposal Hazmat X response Indoor air X X quality

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report use planning Noise pollution Outdoor air quality Poison control Private water X supply safety Public water X X supply safety Radiation X X control Radon control Surface water X X protection Toxicology X X Vector control X X X Other X Key points from Table 11 include:  There is considerable variability in the environmental health activities that the responding health agencies directly performed.  The majority of agencies reported not providing these services as compared to other categories of activities in the survey.  The two activities directly performed by the greatest proportion of health agencies were environmental epidemiology and vector control, with 60 percent of responding agencies reporting directly performing these functions.

Research Activities Health agencies in the USAPI are engaged in a variety of research activities to support public health practice. Table 12 displays the responding agencies and the research activities they reported performing in the two years prior to the survey.

Table 12. Research Activities at Health Agencies, 2012 Guam American Republic of Federated Republic of Samoa Palau States of the Marshall Micronesia* Islands Identify X N/A X topics/questions related to public health practice Develop/refine research N/A plans/protocols for studies

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Recruit study sites X NA and/or participants Collect/exchange/report X X N/A X data from study Analyze/interpret study X X N/A X data or findings Disseminate research N/A findings to key stakeholders Apply research findings N/A to practices within the agency Help other X N/A organizations apply researching findings to practice *Note: the Federated States of Micronesia did not complete this portion of the survey.

Key points from Table 12 include:  The research activities performed by the most agencies were collecting/exchanging/reporting data from a study and analyzing/interpreting study data and findings, with 60 percent of agencies reported performing those activities in the two years prior to the survey.

Jurisdiction-specific Profiles Though the USAPI share some similarities related to their geography and sociocultural and physical environments, each jurisdiction is unique. The health agencies in the five jurisdictions that responded to the ASTHO Profile survey in 2012 vary in their structure and governance, workforce, quality improvement activities, health information management systems, and other activities. Additional information about each of the jurisdictions is presented on the following pages, and reflects the information provided in the 2012 ASTHO Profile survey.

Conclusions Health agencies in the USAPI perform a wide range of services and functions to promote and protect the health of residents in their jurisdictions, much like state health agencies. In 2012, there were a number of activities that all of the responding USAPI reported directly performing. However, there was also variation across the wide range of activities that agencies perform.

Acknowledgements This research was made possible by funding from the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation. ASTHO thanks the Pacific Island Health Officers’ Association for their assistance in data collection. For more information about ASTHO’s Profile survey, please visit www.astho.org/profile, or contact Rivka Liss-Levinson ([email protected]) or Katie Sellers ([email protected]).

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Guam Background Guam is an unincorporated of the United States, and is located in the northwestern of the Pacific . Guam’s land area is 544 kilometers squared, or approximately three times the size of Washington, D.C. The population of Guam was estimated to be 161,001 in 2014, and a large proportion of the population is under the age of 30 years old. Guam’s primary economic activities include military- related activities given a large US military presence on the island, , construction, trans-shipment services, food processing, and textiles.

Agency Structure & Governance The health agency in Guam is under a larger agency or umbrella agency. The agency reported the following top five priorities for the fiscal year in which the survey was completed:  Promote and protect health of the community;  Provide primary health care services to the uninsured and underinsured;  Prevention and control of communicable disease;  Increase awareness on relationship of nutrition to health; and  Compliance for inspections to prevent foodborne illness.

Workforce The agency reported having 142 staff members in 2012. The agency reported having 89 staff assigned to the central office, and 59 staff assigned to community health centers. Two staff members interact with the legislature, and 6.5 full-time equivalents (FTEs) are supported through federal preparedness funds.

Quality Improvement Activities The agency is engaged in a range of quality improvement (QI) activities. Respondents were asked to indicate whether they had completed three health planning activities that are tied to accreditation through the Public Health Accreditation Board (PHAB). Table 1 illustrates the agency’s participation in three territorial health planning activities.

Table 1. Territorial Health Planning Activities and Status Activity Status as of 2012 Territorial health assessment Plan to in the next year Territorial health improvement plan No Agency-wide strategic plan No

The QI framework the agency reported using was plan-do-study-act/plan-do-check-act (PDSA/PDCA) cycles. The formal elements of QI processes that the agency reported employing were identifying root causes, obtaining baseline data, and setting measurable objectives. The agency reported having implemented a formal QI program agency-wide; the elements of this program included having an agency QI council or committee, having staff with time dedicated to QI, having an agency-wide QI plan, and QI resources and training offered to staff. Additionally, staff involvement in QI is supported through training for staff on QI methods, and a QI committee that coordinates staff efforts. The agency also reported having a performance management system fully implemented agency-wide.

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report

When asked about use of the Centers for Disease Control and Prevention’s (CDC) Community Guide, the agency reported using it for program planning, priority setting, and policy development.

Health Information Management Health agencies engage in a range of activities related to health information management, and can vary in the organization of these activities and the related infrastructure. Table 2 displays information related to decision-making authority for health information management issues, and the location of informatics within the territorial health agency.

Table 2. Decision-making Authorities for Health Information Management and Location of Informatics Office Primary decision-making authority for health Chief Information Officer (CIO) or equivalent for information exchanges and technology issues multiple agencies in the territory Overall decision-making authority for agency’s Chief Information Officer (CIO) or equivalent for public health information management systems multiple agencies in the territory Location of informatics office Centralized at the territory level

In 2012, the agency reported that they did not use electronic health information exchanges to monitor or communicate about a range of health topics. The agency reported having systems in place to address several of the Meaningful Use public health objectives, including:  Immunization registry; and  Cancer registry

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Background American Samoa is an unincorporated territory of the United States located in the . American Samoa is comprised of five volcanic islands and two coral ; the total land area is 199 kilometers squared, or slightly larger than Washington, D.C. The population was estimated to be 54,517 in 2014. Tuna and tuna processing are the major industries in the economy in American Samoa, while tourism is a developing sector.

Agency Structure & Governance The health agency in American Samoa is a free-standing or independent agency. The agency reported the following top four priorities for the fiscal year in which the survey was completed:  Non-communicable disease prevention;  Public health infrastructure building;  Health information systems building; and  Workforce development.

In American Samoa, the health official is appointed by the governor and the appointment is confirmed by the legislature; the health official is appointed to a term set by contract to four years. The statutory requirements for the health official include having an MPA or other master’s degree, experience in public health practice or teaching, and executive management experience. The health official directly reports to the governor. The health official can be removed at the will of the governor, or at the will of the cabinet secretary, or through legislative action. Additionally, the budget approval process for the health agency involves both the territory’s budget office and the governor.

Workforce In 2012, the agency reported having 180 staff, which includes 1 part time worker. Six full-time equivalent employees are supported by federal preparedness funds. The workforce is 99% Native Hawaiian/ and 1% Black or African American; 70% of the workforce is female, while 30% is male. Table 3 provides additional information about the average age of employees and years of service to the agency.

Table 3. Average Age of Employees and Years of Service Years Average age of employees 40 Median age of employees 42 Average number years of service 10 Average age of new employees in FY2009 42 Average age of new employees in FY2010 40 Average age of new employees in FY2011 35

The agency reported that 6 percent of its positions, or 12 positions, were vacant at the time of the survey. At the time of the survey, the agency did not have a workforce development plan or workforce development director.

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report

Quality Improvement The agency is engaged in a range of quality improvement (QI) activities. Respondents were asked to indicate whether they had completed three health planning activities that are tied to accreditation through the Public Health Accreditation Board (PHAB). Table 4 illustrates the agency’s participation in three territorial health planning activities.

Table 4. Territorial Health Planning Activities and Status Activity Status as of 2012 Territorial health assessment No Territorial health improvement plan No, but plan to do so in the next year Agency-wide strategic plan No, but plan to do so in the next year

Quality improvement (QI) activities at the health agency were reported to be informal or ad hoc in nature. The QI framework that the agency reported using was plan-do-study-act/plan-do-check-act (PDSA/PDCA) cycles, and the elements of a formal QI process that the agency reported performing were obtaining baseline data and testing the effects of an intervention. The agency reported not having a performance management system in place at the time of the survey.

When asked about use of the Centers for Disease Control and Prevention’s (CDC) Community Guide, the agency reported using it for program planning and priority setting.

Health Information Management Table 5 displays information related to decision-making authority for health information management issues, and the location of informatics within the territorial health agency.

Table 5. Decision-making authority for health information management and location of informatics office Primary decision-making authority for health information Informatics director exchanges and technology issues Overall decision-making authority for agency’s public health Informatics director information management systems Location of informatics office Within the territorial health agency

The agency did not report using electronic health information exchanges to monitor or communicate about a range of health issues. The agency did report having systems in place to address several of the Meaningful Use public health objectives, including:  Electronic syndromic surveillance;  Electronic communicable disease reporting;  Immunization registry;  Cancer registry; and  Electronic communicable disease laboratory reporting.

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Republic of Palau Background The Republic of Palau is an independent nation with a compact of free association with the United States; under the compact the United States received access to Palau’s land and waterways for strategic purposes and Palau receives economic and financial assistance from the United States, including access to funds through the Centers for Disease Control. Palau is comprised of six island groups totaling more than 300 islands in the northwestern portion of the Pacific Ocean; the land area is 459 kilometers squared, or approximately 2.5 times the size of Washington, D.C. The population of Palau in 2014 was estimated to be 21,186. Palau’s economy is supported through aid by the United States, and the government is the largest employer in the nation. Other major industries in the nation include tourism, subsistence , and fishing.

Agency Structure & Governance The health agency in the Republic of Palau is under a larger agency or umbrella agency. Other major responsibilities of the super agency include public assistance, environmental protection, mental health and substance abuse, and the national hospital. The agency reported the following top five priorities for the fiscal year in which the survey was completed:  Non-communicable disease control and healthy workplaces;  Obesity;  Substance use and abuse and mental health;  Injury and violence; and  Emerging and re-emerging infections.

In Palau, the health official is appointed by the president of the and the appointment is confirmed by the legislature; the health official is appointed to a term set by law to four years. The health official directly reports to the president, and can be removed by the president.

The agency reported sharing functions or services on a non-recurring basis for all-hazards preparedness, epidemiology and surveillance, inspections, and administrative services; this sharing is facilitated through both formal and informal agreements.

Workforce In 2012, the agency reported having 193 staff, including 5 part-time workers. Two full-time equivalent employees are supported through federal preparedness funding. The workforce is 98 percent Native Hawaiian/Pacific Islander, one percent White and one percent Asian; 70.5 percent of the workforce is female while 29.5 percent is male. Table 6 provides additional information about the average age of employees and years of service to the agency.

Table 6. Average Age of Employees and Years of Service Years Average age of employees 43 Median age of employees 44 Average number years of service 10

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report

The agency reported that 2.5 percent of its positions, or 5 positions, were vacant at the time of the survey. All of these positions were being actively recruited for.

Quality Improvement The agency is engaged in a number of quality improvement (QI) activities. Respondents were asked to indicate whether they had completed three health planning activities that are tied to accreditation through the Public Health Accreditation Board (PHAB). Table 7 illustrates the agency’s participation in three health planning activities.

Table 7. Health Planning Activities and Status Activity Status as of 2012 National health assessment Yes, five or more years ago National health improvement plan Yes, more than three but less than five years ago Agency-wide strategic plan Yes, more than three but less than five years ago

Quality improvement (QI) activities at the health agency were reported to be informal or ad hoc in nature. The agency also reported having staff with dedicated time to work on QI at the agency, using performance data in an ongoing basis, and providing QI resources and training to staff. Staff involvement in QI is supported through training for staff on QI methods and funding to support staff’s QI efforts. The agency reported having a performance management system fully implemented for specific programs within the agency at the time of the survey.

Health Information Management Table 8 displays information related to decision-making authority for health information management issues, and the location of informatics within the territorial health agency.

Table 8. Decision-making authority for health information management and location of informatics office Primary decision-making authority for health information Chief Information Officer/Chief exchanges and technology issues Medical Information Officer or equivalent for the agency Overall decision-making authority for agency’s public health Chief Information Officer/Chief information management systems Medical Information Officer or equivalent for the agency Location of informatics office Within the national health agency

The agency reported using electronic health information exchanges to monitor conditions including dengue, leptospirosis, and gastroenteritis, and to communicate about disease outbreaks, drug warnings, and vaccination guidelines and requirements. Additionally, the agency reported having systems in place to address several of the Meaningful Use public health objectives, including:  Electronic syndromic surveillance;  Electronic communicable disease reporting;

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report  Immunization registry;  Cancer registry;  Other registry; and  Electronic communicable disease laboratory reporting.

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Federated States of Micronesia Background The Federated States of Micronesia is an independent nation with a compact of free association with the United States; under the compact agreement, the US provides limited funds for social services and allows citizens of the Federated States of Micronesia to enter the US for educational or employment purposes. The Federated States of Micronesia is comprised of four major island groups totaling 607 islands in the North Pacific Ocean; the land area is equal to 702 kilometers squared, or approximately 4 times the size of Washington, D.C. The nation is comprised of four states: , Chuuk, , and , with the capital of being on Pohnpei. The population of the Federated States of Micronesia in 2014 was estimated to be 105,681, with a large proportion of the population being under the age of 25. The primary economic activities include public sector work, subsistence farming, fishing, and tourism.

Agency Structure & Governance The health agency in Micronesia is a free-standing or independent agency. There is one national health agency and four state-run health departments.

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report Republic of the Marshall Islands Background The Republic of the Marshall Islands is an independent nation with a compact of free association with the United States; under the compact the United States provides economic assistance in exchange for use of the Kwajalein as a military base. The Republic of the Marshall Islands is comprised of two archipelagic island chains of 29 atolls, each of which is made of up many small , and five single islands in the Pacific Ocean; the total land area is approximately the size of Washington, D.C. The population in 2014 was estimated to be 70,983. The major drivers of the economy in the Republic of the Marshall Islands are aid from the US government, subsistence farming, and small-scale industries.

Agency Structure & Governance The health agency in the Republic of the Marshall Islands is under a larger agency or umbrella agency. The agency reported the following top four priorities for the fiscal year in which the survey was completed:  Non-communicable diseases;  Multi-drug resistant tuberculosis;  Leprosy; and  Child health.

In the Republic of the Marshall Islands, the health official is appointed by a board or commission, and that appointment is confirmed by a board or commission; there is no set term for the health official’s tenure. The health official can be removed at the will of the governor or relevant cabinet secretary, termination of contract, or by board or commission action. The budget process for the agency involves both the legislature and the national budget office.

The agency reported sharing resources on a continuous, recurring basis with other states or territories, and that there are no laws or regulations related to sharing resources. The agency also reported sharing administrative services on a non-recurring basis.

Workforce In 2012, the agency reported having 535 staff members.

Quality Improvement The agency is engaged in a number of quality improvement (QI) activities. Respondents were asked to indicate whether they had completed three health planning activities that are tied to accreditation through the Public Health Accreditation Board (PHAB). Table 9 illustrates the agency’s participation in three health planning activities.

Table 9. Health Planning Activities and Status Activity Status as of 2012 National health assessment No National health improvement plan No Agency-wide strategic plan No

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report The agency reported that formal QI activities have been implemented in specific programmatic or functional areas, but not implemented agency-wide. The elements of a formal QI process that the agency reported performing were mapping a process, identifying root causes, obtaining baseline data and setting measurable objectives. The agency also reported having a QI council or committee, and using performance data on an ongoing basis for quality improvement. The agency supports staff involved in QI activities through a recognition award for staff QI excellence, inclusion of participation in QI as a part of employee performance goals, a QI committee coordinating agency QI efforts, and funding to support staff involvement in QI. Additionally, the agency reported having a performance management system fully implemented for specific programs within the agency at the time of the survey.

When asked about use of the Centers for Disease Control and Prevention’s (CDC) Community Guide, the agency reported using it for program planning.

Health Information Management Table 10 displays information related to decision-making authority for health information management issues, and the location of informatics within the health agency.

Table 10. Decision-making authority for health information management and location of informatics office Primary decision-making authority for health information Chief Information Officer/Chief exchanges and technology issues Medical Information Officer or equivalent for the agency Overall decision-making authority for agency’s public health Chief Information Officer/Chief information management systems Medical Information Officer or equivalent for the agency Location of informatics office Within the national health agency

The agency did not report using electronic health information exchanges to monitor or communicate about a range of health issues. The agency reported having systems in place to address several of the Meaningful Use public health objectives, including:  Electronic communicable disease reporting;  Immunization registry; and  Cancer registry.

ASTHO US-Affiliated Pacific Islands (USAPI) Profile Report